AMPUTEE INTERVENTIONS, TRAINING, OI

Question 1

What is osteointegration?

Answer 1

Bone anchored prosthesis

“The anchoring of a surgical implant by the growth of bone around it without fibrous tissue formation at the interface”

Question 2

Where did OI first have its start?

Answer 2

dentistry

ex: dental implant - first one 1965

Question 3

What is the most difficult part of OI surgery?

Answer 3

soft tissue closure

Question 4

Screw fit vs press fit system OI

Answer 4

SCREW FIT
-FDA approved

PRESS FIT
-usually transfemoral amputees
-also for ease, functionality
-great for those who don’t tolerate a socket
-NOT FDA approved; done under exemption
-pressure holds the prosthetic in place
-very quick to don and doff with less skin problems

Question 5

OI rehab vs Socket rehab

Answer 5

Not much different

-myodesis: muscle to bone
-myoplasty: muscle to muscle
*both used to foster distal muscle stabilization after amputation

-rehabilitation to prevent contractures

-improved biomechanics after OI rehab compared to socket rehab
–> glut med function
–> closed chain
–> better proprioceptive feedback

Question 6

Rehab screw fit vs press fit

Answer 6

SCREW FIT
-2 stage surgery: 1st: implant, close 4-6 months rest, then 2nd surgery with more ST attention
-REHAB: 6 MONTHS
* 3 wks progressive exercise
* 3 wks progressive WB on short prosthesis
* 3 wks progressive WB on long prosthesis
* 4 wks progressive WB gait in II bars/crutches
* 4 wks full WB gait 2 crutches
* 6 wks single crutch/cane short distance 2 canes/crutches longer distance, uphill, downhill, speed
* 3 wks single A device community level, unlimited distance

PRESS FIT
-2 stage surgery; single stage for TTA
-stage 1- 6 wks rest
-stage 2- 2 days rest
REHAB:
-3 wks: full WB progressing from standing–> 2 crutches community level
-3-6 wks: progress through 2 crutches –> canes–> walking sticks–> no A device
-SHORTER PROCESS

-keep pain level <4/10
-keep biomechanical symmetry

Question 7

Position of femur with OI compared to standard amputation with socket

Answer 7

-femur is not aligned properly with the socket as opposed to OI

-with the socket, the femur is pushed to the left –> makes you trunk lean
–> glutes and stabilizers are on stretch

-alters the biomechanics of gait

-with OI–> since the femur is aligned properly–> the glut med can actually work to stabilize the hip

BIOMECHANICAL ADVANTAGE OF OI:
-OI: closed chain
-can maintain level pelvis
-proximal stability from gluteus medius

Question 8

Outcomes and data of OI

Answer 8

-100% of patients would do it again (even those with complications)

-Patient-reported outcomes (comparing OI to standard transfemoral amputation socket prosthesis)
-improved PROMs overall

Question 9

Biomechanics changes one-year following OI in individuals with transfemoral lower limb amputation

Answer 9

-glut med activation increased
-glut max activation inc.
-increased knee extension moment
-increased trunk lateral flexion moment

Question 10

Adverse events after OI

Answer 10

pain

infection
-20% rate of infection over 15 year follow up
-superficial most common

loosening or hardware failure
-may need revision

poor healing

fracture (test sensation)

HO

granulation tissue

WATCH FOR
-pain
-infection
-loosening hardware
-poor healing
-poor sensation
-TTA:
–longer lever arm
–rotation
–knee OA

Question 11

Conservative pain management

Answer 11

pendulums

decreased WB

bike with no resistance

rest

pain killers

modalities

wrapping/compression

manual therapy

stoma considerations

Question 12

Activities to avoid with OI

Answer 12

plyometric and high level activities:

running
football
powerlifting
snowboarding
soccer
wakeboarding
skydiving

Question 13

How long does post-amputation/pre-prosthetic mobility training take?

Answer 13

3- 6 months to fully walk and use their prosthetic independently

Question 14

Supine strengthening

Answer 14

hip adduction/abduction
quad and glute sets
hamstring stretches
ab crunches

Question 15

Prone strengthening

Answer 15

lying prone propped on elbows
isometric glute sets–> hip extension

Question 16

side lying strengthening

Answer 16

hip abduction/extension

Question 17

seated strengthening

Answer 17

seated push-ups

trunk twists

marching

quad sets, knee extension

Question 18

standing strengthening

Answer 18

hip raises

mini squats

hip 4 ways

Question 19

Goal for household ambulation pre-prosthetic

Answer 19

goal: modified independent for 50 feet with LRAD

Question 20

Goal for stairs pre-prosthetic

Answer 20

single-limb hopping or bumping using LRAD and railings

Question 21

Interventions for phantom limb sensation/pain

Answer 21

mirror therapy
-looking at sound limb

desensitization techniques

visual imagery

Question 22

Interventions for residual limb pain

Answer 22

movement and positioning

compression

habituation and desensitization

Question 23

Guidelines for donning and doffing

Answer 23

• Invert liner as far as possible - contact directly against the end of
  residual limb, roll on the interface
• No wrinkles, folds or trapped air inside the liner
• Add appropriate ply of socks
• Stand and weight bear to expel air
• Progress wear schedule
• Continue residual limb management and skin checks for tolerance

Question 24

Training for weight acceptance onto socket/prosthetic

Answer 24

PARALLEL BARS
-sit to stands

standing trials
-scales to see how much weight on each (weight shiting)
-rhythmic stabilization

Question 25

Dynamic weight acceptance training

Answer 25

-stepping in place -toe taps -step-ups --tap sound limb on step --->promote weight shift onto the prosthetic side -proprioception: roll ball under sound side to promote dynamic balance and weight shift -pre-gait activities

Question 26

Progression of support

Answer 26

parallel bars--> FWW--> bilateral forearm crutches--> unilateral forearm crutch--> cane --> no AD

Question 27

Criteria for taking the leg home; approximately 2-8 visits depending on progress:

Answer 27

-can don/doff independently and correctly without cueing -sit to stand independently with the use of AD -can stand x2 min independently with use of AD -can ambulate 100 feet with LRAD on surface compliant with home floor -can negotiate single step with LRAD independently -able to negotiate stairs ind. if they are present at home

Question 28

Functional mobility goals with prosthetic

Answer 28

TRANSFERS Goal: Modified independent sit to stand with prosthesis with least restrictive assistive device (LRAD) HOUSEHOLD AMBULATION Goal: modified independent for 50-100 feet with prosthesis with LRAD Goal: modified independent for lateral walking and pivoting in tight spaces with LRAD COMMUNITY AMBULATION Goal: modified ind. negotiation of slopes, uneven surfaces, and curbs with LRAD STAIRS Goal: modified independent for single limb hopping or bumping with prosthesis

Question 29

Criteria needed to disengage knee (locking knee)

Answer 29

knee must be in full extension 70% BW toe load (DF moment) -default is resistance to flexion

Question 30

Walking with mechanical knee key points

Answer 30

-need strong extension of glutes/hams -often lateral trunk flexion compensation for improper trunk/pelvic rotation and knee flexion -often uneven stride length/rhythm

Question 31

Benefits of microprocessor knee

Answer 31

* Stumble recovery * Ability to ride the knee down stairs, ramps, rough terrain * Stability on uneven surfaces * Controlled sitting and kneeling movements are possible * Less user concentration on the prosthesis * Energy-efficient gait with greater symmetry * can perform reciprocal stepping on stairs

Question 32

GAIT TRAINING PROGRESSION

Answer 32

IN PARALLEL BARS -practice riding knee in standing -step length practice -loading the toe -smooth rhythm -equal sound for heel strike OUT OF BARS: -resisted pelvic rotation -facilitate shoulder rotation -speed changes -flat treadmill